HR Disability Consent Form

HR Disability Consent Form

Purpose: This form documents the employee's request for disability-related accommodation, provides the employer with authorization to obtain medical information necessary to evaluate the request, and obtains consent for limited disclosures and background verification as required for the interactive accommodation process. Complete all applicable fields and attach supporting documentation where requested.

Personal Information

Employee Name:

Position Information

Start Date with Employer:

Disability and Accommodation Information

I am requesting an accommodation for a disability: Yes

Desired Start Date for Accommodation:    Anticipated Duration:

Medical Provider Information & Authorization

I authorize the employer and designated representatives to contact the above-named health care provider(s) for the purpose of obtaining medical information necessary to evaluate my request for reasonable accommodation, including confirmation of diagnosis, functional limitations, recommended accommodations and expected duration: I authorize this contact

I also authorize the employer to provide the treating provider with relevant job descriptions and to communicate regarding restrictions, accommodations, work status, and return-to-work planning: I authorize this communication

Release of Medical Records: I understand that medical information obtained under this authorization will be retained in a confidential medical file maintained separately from my personnel file and will be used only to assess and implement reasonable accommodations as permitted by applicable law.

Supporting Documentation

I will provide medical documentation supporting the condition and need for accommodation upon request: Yes

Authorization to Contact Previous Employers & Background Checks

For the purposes of verifying employment history and job-related qualifications, and where relevant to the accommodation process, I authorize the employer to contact my previous employers and professional references, and to obtain background checks that may include job history verification, criminal background checks, and other job-related screenings as permitted by law: I consent

I also authorize previous employers and listed references to provide information concerning my previous employment and job performance to the employer and its authorized agents: I authorize

Employment History (Most Recent)

Dates Employed:

Employment History (Previous)

Dates Employed:

Education

Graduation Date:

References

Legal Disclosures

At-Will Employment: Nothing in this form alters the employment relationship; except where a separate written agreement exists, employment with the employer is at-will and may be terminated by either party at any time, with or without cause or notice, consistent with applicable law.

Equal Employment Opportunity: The employer provides equal employment opportunity and considers requests for reasonable accommodation in accordance with applicable law. Requests will be evaluated through an individualized interactive process.

Certifications and Authorizations

Applicant Certification: I certify that all information provided on this form and any attached documentation is true, accurate and complete to the best of my knowledge. I understand that providing false or misleading information may result in denial of accommodations or disciplinary action, up to and including termination.

Authorization to Release Medical Information: I hereby authorize my treating health care provider(s) to release to the employer and its designated representatives such medical information as is necessary to assess my request for accommodation, including diagnosis, prognosis, functional limitations, treatment related restrictions, and expected duration. I understand that this authorization is limited to information relevant to the accommodation request and does not authorize disclosure of unrelated medical records.

Revocation: I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. If not earlier revoked, this authorization will remain valid for the duration of the accommodation request and any subsequent interactive process related to this request.

Confidentiality: Medical information obtained pursuant to this authorization will be treated as confidential and maintained in separate medical records, disclosed only to individuals with a need to know for evaluation or implementation of reasonable accommodation, or as otherwise required or permitted by law.

Acknowledgment

By signing below I acknowledge that I have read and understand the statements and authorizations in this form, that I consent to the release of limited medical information as described above, and that I consent to the employer contacting previous employers and references for verification as necessary to consider my request. I also acknowledge that the employer may require documentation to support the need for accommodation and that a determination will be made based on the interactive process and available reasonable accommodations.

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